Parental concerns and distress after paediatric traumatic brain injury: a qualitative study

Objective: To determine concerns of parents associated with high distress levels in the care of children with traumatic brain injury (TBI).

Setting and participants: Primary care hospital/medical centre-based study on parental perspectives following TBI in school age children (n = 100; 19 orthopaedic trauma controls and 81 children with a history of TBI).

Main outcome measures: Verbatim reports regarding major concerns on the Child Behaviour Checklist (CBCL), as well as parental ratings regarding their overall distress level when caring for the child.

Results: Summary of verbatim comments indicated that parents who report high levels of distress in the care of their children were specifically concerned about the child's poor school performance, lack of friends, inability to control angry feelings and apathy. Fear of the future consequences of the TBI was also cited as a major concern. Parent ratings of distress level was significantly, but weakly correlated with the severity of TBI in their children (r = +0.26, n = 94, p = 0.01).

Conclusion: Reports of severe distress in the care of TBI children by parents are seen at all levels of severity of TBI. Addressing these parental concerns may increase parental engagement in the rehabilitation process.     

Heart rate variability (HRV) of patients with traumatic brain injury (TBI) during the post-insult sub-acute period

Objective: To evaluate heart rate variability (HRV) of patients with traumatic brain injury (TBI).

Methods: By a prospective study, the HRV was assessed in 20 patients with TBI during the sub-acute period post-injury (the first test was performed at a mean time post-insult of 38 days) and a matched control. The patients were examined twice, 1 month apart. The assessment included HRV (both in time and frequency domains), GCS, length of coma, brain CT, FIM and FAM.

Results: A significant difference was found between patients and controls concerning HRV total power, i.e. frequencies between 0.01-0.6 Hz (high frequency p = 0.003, low frequency p = 0.013, total power p = 0.034) and for standard deviation of RR interval p = 0.011. HRV changes were related more to the timing of the evaluation than to the severity of the brain damage.

Conclusion: HRV differed of patients with TBI and in the control group. Tendency to HRV normalization changes was detected during the first 3 months after the injury, which suggests recovery of the autonomic nervous system.     

Assessment of intra-cranial pressure after severe traumatic brain injury by transcranial Doppler ultrasonography

Primary objective: To investigate the potential of transcranial Doppler ultrasonography in estimating post-traumatic intra-cranial pressure early after severe traumatic brain injury.

Research design: The group of 24 patients was analysed for the observation of an early post-traumatic cerebral haemodynamic by middle cerebral artery blood velocity measuring.

Methods and procedures: The standard method of measuring the mean blood middle cerebral artery velocity by transcranial Doppler ultrasonic device was performed.

Main outcomes and results: The increased duration of intra-cranial hypertension correlated to the middle cerebral artery low blood velocity (p = 0.042; r = -0.498) (n = 17) and to elevated pulsatility indices (p = 0.007; r = 0.753) (n = 11) significantly. The increased duration of lowered cerebral perfusion pressure correlated to the middle cerebral artery low blood velocity significantly (p = 0.001; r = -0.619) (n = 24).

Conclusions: The significance of transcranial Doppler ultrasonography as a method to estimate an early post-traumatic intra-cranial pressure after severe brain injury was confirmed. This simple and non-invasive technique could be easily used in daily clinical practice and precede intra-cranial pressure monitoring in selected patients.     

Voxel-based statistical analysis of cerebral blood flow using Tc-99m ECD brain SPECT in patients with traumatic brain injury: group and individual analyses

Purpose: Statistical parametric mapping (SPM) was applied to brain perfusion single photon emission computed tomography (SPECT) images in patients with traumatic brain injury (TBI) to investigate regional cerebral abnormalities compared to age-matched normal controls.

Method: Thirteen patients with TBI underwent brain perfusion SPECT were included in this study (10 males, three females, mean age 39.8 ± 18.2, range 21 ∼ 74). SPM2 software implemented in MATLAB 5.3 was used for spatial pre-processing and analysis and to determine the quantitative differences between TBI patients and age-matched normal controls.

Results: Three large voxel clusters of significantly decreased cerebral blood perfusion were found in patients with TBI. The largest clusters were area including medial frontal gyrus (voxel number 3642, peak Z-value = 4.31, 4.27, p = 0.000) in both hemispheres. The second largest clusters were areas including cingulated gyrus and anterior cingulate gyrus of left hemisphere (voxel number 381, peak Z-value = 3.67, 3.62, p = 0.000). Other clusters were parahippocampal gyrus (voxel number 173, peak Z-value = 3.40, p = 0.000) and hippocampus (voxel number 173, peak Z-value = 3.23, p = 0.001) in the left hemisphere. The false discovery rate (FDR) was less than 0.04.

Conclusion: From this study, group and individual analyses of SPM2 could clearly identify the perfusion abnormalities of brain SPECT in patients with TBI. Group analysis of SPM2 showed hypoperfusion pattern in the areas including medial frontal gyrus of both hemispheres, cingulate gyrus, anterior cingulate gyrus, parahippocampal gyrus and hippocampus in the left hemisphere compared to age-matched normal controls. Also, left parahippocampal gyrus and left hippocampus were additional hypoperfusion areas. However, these findings deserve further investigation on a larger number of patients to be performed to allow a better validation of objective SPM analysis in patients with TBI.     

Increased inattentional blindness in severe traumatic brain injury: evidence for reduced distractibility?

Primary objective: To examine the role of selective attention and visual perception in medicating inattentional blindness in a severe traumatic brain injured sample.

Research design: Cross-sectional design with age and education matched control sample.

Methods and procedures: Twenty participants with severe traumatic brain injury (n = 10) and matched controls (n = 10) completed a series of tests of focused attention (Stroop test), divided attention (Trail Making Test), visual perception (Visual Object and Space Perception Battery) and two tasks of inattentional blindness.

Main outcomes and results: The group with severe TBI were significantly slower on the Stroop test and TMT and displayed significantly elevated Stroop interference and TMT ratio scores. On the inattentional blindness tasks, fewer TBI participants identified a distracting stimulus.

Conclusion: The results indicate severe TBI is associated with deficits to focused and divided attention with the finding of a potentially more debilitating impairment arising from reduced distractibility following severe TBI.     

Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial

Objective: To evaluate the effects of an increase in the intensity of rehabilitation on the functional outcome of patients with traumatic brain injury (TBI).

Design and methods: Sixty-eight patients (age 12-65 years) with moderate-to-severe TBI were included. They were randomized into high (4-hour/day) or control (2-hour/day) intensity rehabilitation programmes at an average of 20 days after the injury. The programmes ended when the patients achieved independence in daily activities or when 6 months had passed.

Outcome and results: No significant differences were found in the Functional Independence Measure (FIM) (primary outcome) and Neurobehavioural Cognitive Status Examination (NCSE) total scores between the two groups. There were significantly more patients in the high intensity group than in the control group who achieved a maximum FIM total score at the third month (47% vs. 19%, p = 0.015) and a maximum Glasgow Outcome Scale (GOS) score at the second (28% vs. 8%, p = 0.034) and third months (34% vs. 14%, p = 0.044).

Conclusions: Early intensive rehabilitation may improve the functional outcome of patients with TBI in the early months post-injury and hence increase the chance of their returning to work early. Intensive rehabilitation in this study speeded up recovery rather than changed the final outcome.     

Behaviour and school performance after brain injury

Primary objective: To examine the relationship between behavioural problems and school performance following traumatic brain injury (TBI).

Methods and procedures: Subjects: 67 school-age children with TBI (35 mild, 13 moderate, 19 severe) and 14 uninjured matched controls. Parents and children were interviewed at a mean of 2 years post-TBI. Teachers reported on academic performance and educational needs. Children were assessed using the Vineland Adaptive Behaviour Scales (VABS) and the Weschler Intelligence Scale for Children (WISC-III).

Main outcomes and results: Two-thirds of children with TBI exhibited significant behavioural problems, significantly more than controls (p = 0.02). Children with behavioural problems had a mean IQ ∼ 15 points lower than those without (p = 0.001, 95% CI: 7-26.7). At school, 76%(19) of children with behavioural problems also had difficulties with schoolwork. Behavioural problems were associated with social deprivation and parental marital status (p ≤ 0.01).

Conclusions: Children with TBI are at risk of developing behavioural problems which may affect school performance. Children with TBI should be screened to identify significant behavioural problems before they return to school.     

Work-related deaths and traumatic brain injury

Background: Traumatic brain injury (TBI) at the workplace is a significant contributor to the number of work-related deaths that occur per year. This study aimed to quantify and characterize these deaths in Ontario.

Methods: The study design was a case series with analytic and surveillance components. Data was obtained from the Chief Coroner's Office of Ontario from 1996-2000.

Results: A total of 488 work-related injury fatalities were identified. Evidence of TBI was apparent in 45% of these cases (n = 211). Industries with the highest rate of work-related TBI mortality expressed per 100 000 working population included primary industry (59.1), agriculture (24.5), construction (20.0) and transportation/communications/utilities industries (13.9). Deaths involving TBI were more likely to be due to falls than non-TBI-related deaths among workers (p = 0.0001).

Conclusions: Results from this research indicate that prevention programmes should focus on decreasing falls at all ages and increasing the use of personal protective equipment.     

Orienting responses and habituation among persons with traumatic brain injury: distinctive aspects of apathetic and disinhibited behaviours

Purpose: This study focused on basic attentional impairments among persons with TBI who were behaviourally evaluated as suffering from either apathetic or disinhibition symptoms.

Methods: Differences in orienting responses (ORs) and habituation rates were examined between patients (n = 18) and controls (n = 18) and between two TBI sub-groups: Apathetic (n = 9) and disinhibited patients (n = 9). Skin conductance responses were used to measure ORs and habituation rates.

Results: The results revealed that the TBI patients did not differ from the control group in their ORs and habituation rate. However, marked differences emerged between the two TBI sub-groups. Apathetic patients presented attenuated ORs and more rapid habituation as compared to disinhibited patients. The findings indicate that when examining attentional impairments in the TBI population, different attentional patterns may counterbalance each other.

Conclusion: As a result, the performance of the entire group may not adequately reflect the basic attentional impairments of its members. The study of attention deficits may benefit from consideration of systematic neuro-pathological differences within the TBI population.     

Executive dysfunction and domestic violence

Primary objective: To replicate previous studies which have reported a high prevalence of traumatic brain injury (TBI) in partner-abusive men and to extend research in this area by determining the prevalence of executive dysfunctions, which have been linked with both TBI and violent behaviour.

Research design: Thirty-eight men with criminal convictions for violence and who were receiving treatment for abusing their partners were assessed.

Methods and procedures: Subjects with a self-reported history of TBI (n = 22) were compared to the non-TBI group (n = 16) on various psychological measures.

Main outcomes and results: The two groups were not significantly different on the variables of age, pre-morbid IQ, self-esteem and alcohol use. The TBI group scored more poorly than the non-TBI group on a measure of current IQ and two of the three measures of executive functioning.

Conclusion: The presence of executive dysfunction has implications for the design of successful intervention programmes with this sub-group of batterers.     

Traumatic brain injury, psychiatric disorders and suicide: a population-based study of suicide victims during the years 1988-2004 in Northern Finland

Background: Depression and substance abuse are common among patients with traumatic brain injury (TBI). However, previous studies have not examined the temporal association between psychiatric disorders, TBI and suicide.

Objective: To study the prevalence of TBI injury among suicide victims; to determine the association of suicide, psychiatric disorders and TBI severity; and to examine the effect of pre- and post-traumatic psychiatric disorders on their remaining life-time.

Methods: This study examined all suicides (n = 1877) committed during a 16-year period in the province of Oulu, Finland. The information of suicide victims was extracted from the official death certificates and the National Hospital Discharge Registers.

Results: TBI was found in 5.5% (n = 103) of the victims. Compared to the victims without TBI, those with TBI had significantly more hospital-treated psychiatric and alcohol disorders. If TBI subjects had comorbid psychiatric disorders, the time period between TBI and suicide was under 3 years in ∼ 90% of victims in this suicide population.

Conclusions: Seriousness of injury, male gender, older age, being unemployed and presence of psychiatric and alcohol disorders are important to identify as possible predictors for suicidal behaviour in TBI patients. Further studies are required to shed light on interventions aimed at better life management.     

The effects of mild traumatic brain injury on confrontation naming in adults

Primary objective: To compare confrontation-naming in adults with MTBI to a group of normal adults under increased processing load conditions.

Research design: A randomized block, repeated measures design was used to examine confrontation-naming response latency and accuracy using a computerized experimental program.

Methods and procedures: Twenty-four adults having sustained a MTBI (aged 18-53) and 24 age-matched controls named pictures from three levels of vocabulary as quickly and accurately as possible. All MTBI participants were assessed with the Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) for later comparison.

Main outcomes and results: The results revealed a main effect of group ( p ≤ 0.001) for the latency data and a group by vocabulary level interaction ( p = 0.043) for the accuracy data. No significant correlations were found between response latency and accuracy with performance on the SCATBI. Reaction time measures may reveal inefficiencies not tapped by traditional measures.     

Long-term neuropsychological performance in a cohort of children and adolescents after severe paediatric traumatic brain injury

Objective: The purpose of the present study was to evaluate progress in neuropsychological performance in children and adolescents with severe paediatric traumatic brain injury (TBI), from admission to the rehabilitation centre up to 3-12 years after the trauma.

Methods: Children and adolescents (n = 31, mean age at injury 11.8 years, SD = 3.8; at follow-up 18.8 years; SD = 4.5) who all had suffered a TBI participated. A comprehensive neuropsychological test battery was administered at the start of rehabilitation (T1), around discharge (T2) and in the long-term (at least 3 years after rehabilitation; T3). T1 and T2 were clinical assessments; T3 was executed as a follow-up measurement for this study.

Results: At T1 and T2, most problems were in the domains of attention, memory and executive functioning. At the start of rehabilitation most deficits were with performal intelligence (61%); at discharge (mean length of stay 411 days) considerably less children had severe deficits on the intelligence domain (23%). At long-term follow-up, most problems were in the domains attention, mental speed and memory. From admission to discharge 42% of the children improved on two or more cognitive tests; from discharge to follow-up this percentage was 13%.

Conclusions: In this unique study a clinical cohort of children with severe TBI was followed for many years after injury. Most cognitive deficits were found in the early phase of rehabilitation. Most children did improve on cognitive functioning (40%) during the first year after their injury, whereas at follow-up most children had not changed. At follow-up, more than half of the children (54%) attended a regular school or had a regular job, corresponding to their age and pre-morbid functioning.     

Breaking the news of traumatic brain injury and incapacities

Primary objective: This paper presents research results regarding disclosure of traumatic brain injury (TBI) diagnosis and resulting deficits of a study aiming to investigate the experiences of individuals who had sustained a TBI, their families, the physicians and health professionals involved, from the critical care episodes and subsequent rehabilitation.

Research design: Semi-structured interviews were conducted with individuals who had sustained a TBI (n = 8) and their families (n = 8) as well as with the health professionals (or service providers) (n = 22) and physicians (n = 9) who provided them care.

Main outcomes and results: Results revealed that the quality of the disclosure is strongly influenced by the medical uncertainty surrounding the TBI and the difficulties of healthcare professionals in dealing with the family's emotions.

Conclusions: Delivering bad news is always difficult, but it is possible to make this harrowing experience easier and, in so doing, enhance patient and family resilience.     

The experiences of individuals with a traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum

Primary objective: To investigate the experiences of individuals who had sustained a traumatic brain injury, their families and the physicians and health professionals involved, from the critical care episodes and subsequent rehabilitation.

Research design: Semi-structured interviews were conducted with individuals who had sustained a TBI (n = 8) and their families (n = 8) as well as with the health professionals (or service providers) (n = 22) and physicians (n = 9) who provided them care.

Main outcomes and results: Results revealed the difficulties encountered by the different people involved, from the standpoint of the readjustment of the individual with the TBI and their family, the relationships among the various actors and the continuity of care.

Conclusions: This study brings to light the importance of including the family and the person with a TBI in the care process by calling for their participation and by setting up suitable structures that prioritize a meaningful partnership among the key individuals.     

Validation of the Memory and Behavior Problems Checklist-1990R for use in acquired brain injury

Objective: The Memory and Behavior Problems Checklist-1990R (MBPC-1990R) is a carer-rated measure of (a) problem behaviours and (b) corresponding carer reaction. Although originally developed and validated for dementia, its items are relevant to acquired brain injury (ABI). This study evaluated its validity in this population.

Design: Cross-sectional study.

Methods: In a national postal survey carried out to inform service planning, 222 family carers of adults with TBI (49%), strokes (26%), infections (18%), other (7%) completed the MBPC-1990R, Head Injury Behaviour Scale (HIBS), Barthel Index (BI), Northwick Park Dependency Score (NPDS), Carer Burden Interview (CBI), WHOQOL-BREF and GHQ-28.

Results: MBPC-1990R problems correlated well with HIBS problems (r = 0.70), as did MBPC-1990R carer reaction with HIBS distress (r = 0.78) and CBI (r = 0.73) scores, indicating good convergent validity. Discriminant validity was inferred from absent/weak correlations between MBPC-1990R problems and both BI (r = -0.02) and NPDS (r = 0.24); likewise between MBPC-1990R carer reaction and WHOQOL-BREF physical, psychological, social, environmental sub-scales (r = -0.32 to -0.41) and GHQ-28 scores (r = 0.35). Factor analysis revealed excessive, cognitive, aggressive and passive/low mood sub-scales, which showed good internal consistency and varied across ABI groups.

Conclusions: The MBPC-1990R is supported as a measure of problem behaviours and carer reaction in ABI. Further validation in ABI groups is recommended.     

Occurrence of ocular disease in traumatic brain injury in a selected sample: a retrospective analysis

Primary objective: To determine retrospectively the relative risk of ocular disease in a selected, visually-symptomatic sample of clinic patients having traumatic brain injury (TBI; n = 160) vs. cerebrovascular accident (CVA; n = 60), with all initially presenting at the clinic with symptoms and/or signs of vision dysfunction.

Methods and procedures: To review retrospectively 220 medical records of individuals with TBI (n = 160) vs. CVA (n = 60), as determined by a computer-based query spanning the years 2000-2003, to ascertain the frequency of occurrence of ocular disease in the two major sub-groups of acquired brain injury.

Main outcomes and results: Conditions with high relative risk unique to TBI included corneal abrasion, blepharitis, chalazion/hordeolum, dry eye, traumatic cataract, vitreal prolapse and optic atrophy. This is distinct from those ophthalmic conditions unique to CVA, which included sub-conjunctival haemorrhage and ptosis.

Conclusion: These new findings should alert clinicians to the potential increased frequency of occurrence of specific ocular diseases in a selected, visually-symptomatic population with TBI and their associated rehabilitative and quality-of-life implications.     

The relationship between clients' cognitive functioning and the therapeutic working alliance in post-acute brain injury rehabilitation

Objective: To examine the impact of brain-injured patients' cognitive abilities on their working alliance (WA) with their therapist in post-acute rehabilitation.

Design: Cognitive tests were administered to brain-injured individuals at the beginning of post-acute, holistic brain-injury rehabilitation. Clients as well as their primary therapists rated their mutual WA at four time points throughout a 14-week rehabilitation programme. Subjects consisted of 86 clients as well as their primary therapists. Clients had suffered a traumatic brain injury (n = 27), a cerebrovascular accident (n = 49) or another neurological insult (n = 10).

Measures: (1) Neuropsychological tests of attention, memory and higher cognitive functions; (2) the Working Alliance Inventory, client and therapist short form.

Results: Overall, the relationships between cognitive tests and WA ratings were weak. The tests of attention, memory and higher cortical functions were differentially related to clients' and therapists' view of their mutual WA at the different stages of their collaborative work.

Discussion and conclusion: Clients' cognitive profile affects clients' and therapists' view of their WA in different ways. The weakness of the correlations between cognitive tests and WA ratings may indicate that a good WA is achievable also with clients with severe cognitive difficulties.